Resuscitation
A 6 year old child is brought to the Emergency Department by her concerned parents. She has been febrile for several days and not eating or drinking properly, today they noted a non-blanching rash over both lower limbs. Whilst being moved to the resuscitation area she becomes unresponsive. You are unable to feel a central pulse and start CPR. A colleague obtains intravenous access and attaches the defibrillator, the monitor shows asystole. What is the next management step?
Answer:
Asystole is the most common arrest rhythm in children because the response of the young heart to prolonged severe hypoxia and acidosis is progressive bradycardia leading to asystole. If asystole or PEA is identified, give adrenaline 10 micrograms/kg (0.1 ml/kg of 1:10,000 solution) intravenously or intraosseously immediately, and then every 4 minutes if there is no ROSC.Paediatric Cardiorespiratory Arrest: Advanced Life Support
Resuscitation
Last Updated: 11th August 2022
Cardiac arrest has occurred where there is no effective cardiac output. Before any specific therapy is started, effective basic life support must be established.
Cardiac arrest rhythms
- Shockable
- Ventricular fibrillation
- Pulseless ventricular tachycardia
- Non-shockable
- Asystole
- Asystole is the most common arrest rhythm in children because the response of the young heart to prolonged severe hypoxia and acidosis is progressive bradycardia leading to asystole.
- Pulseless electrical activity (PEA)
- PEA may be due to an identifiable and reversible cause. In children the most common causes are hypovolaemia and hypoxia. Trauma is also most often associated with a reversible cause of PEA. This may be severe hypovolaemia, tension pneumothorax or pericardial tamponade. PEA is also seen in hypothermic patients and in patients with electrolyte abnormalities.
- Asystole
Management of non-shockable rhythms
If asystole or PEA is identified, give adrenaline 10 micrograms/kg (0.1 ml/kg of 1:10,000 solution) intravenously or intraosseously immediately, and then every 4 minutes if there is no ROSC.
Adrenaline, through alpha-adrenergic mediated vasoconstriction, acts to increase aortic diastolic pressure during chest compressions and thus coronary perfusion pressure and the delivery of oxygenated blood to the heart. It also enhances the contractile state of the heart and stimulates spontaneous contractions.
Consider reversible causes of cardiac arrest:
- Hypoxia (most common)
- Hypovolaemia (trauma, anaphylaxis and sepsis)
- Hyperkalaemia, hypokalaemia, hypocalcaemia
- Hypothermia (drowning)
- Tension pneumothorax (trauma)
- Tamponade (trauma)
- Toxic substances
- Thromboembolic events (rare)
Management of shockable rhythms
Ventricular fibrillation and pulseless ventricular tachycardia are less common in children but may be seen in sudden collapse, in hypothermia, in poisoning from tricyclic antidepressants and in those with cardiac disease.
If ventricular fibrillation or ventricular tachycardia is identified, an asynchronous shock of 4 J/kg should be given immediately and CPR immediately resumed without reassessing the rhythm or checking for a pulse.
Appropriately sized adhesive defibrillation pads should be used. Recommended sizes are 4.5 cm for children < 10 kg and 8-12 cm for children > 10 kg. One pad is placed over the apex in the mid-axillary line, whilst the other is put immediately below the clavicle just to the right of the sternum.
If an automated external defibrillator (AED) is being used, a standard adult shock should be given in children over 8 years, and attenuated paediatric paddles should be used with the AED in children under 8 years old. For the infant less than 1 year, a manual defibrillator that can be adjusted to give the correct shock is recommended.
Two minutes after the first shock, pause chest compressions briefly to reassess the monitor. If VF/pVT ius still present, give a second shock of 4 J/kg an immediately resume CPR. Repeat after a further two minutes. After the third shock, give adrenaline 10 micrograms/kg and amiodarone 5 mg/kg intravenously or intraosseously. After the fifth shock, give a further adrenaline 10 micrograms/kg and amiodarone 5 mg/kg intravenously or intraosseously. Continue giving shocks every two minutes and give adrenaline after every alternate shock (i.e. every 4 minutes).
Lidocaine (1 mg/kg IV/IO) is an alternative to amiodarone if the latter is unavailable).
Magnesium 25 - 50 mg/kg (max 2 g) is indicated in children with hypomagnesaemia or with polymorphic VT (torsade de pointes) regardless of the cause.
Drugs used in cardiac arrest
Weight estimation calculations:
- 0 - 12 months = (0.5 x age) + 4
- 1 - 5 years = (2 x age) + 8
- 6 - 12 years = (3 x age) + 7
| Drug | Dose | Administration |
|---|---|---|
| Adrenaline | 10 micrograms/kg (0.1 ml/kg of 1:10,000 solution) | Shockable rhythm: Give after third shock, and then after alternate shocks (every 4 minutes)
Non-shockable rhythm: Give immediately and then every 4 minutes |
| Amiodarone | 5 mg/kg | Shockable rhythm: Give after the third and fifth shock |
| Lidocaine | 1 mg/kg | Can be used as alternative to amiodarone if the latter is unavailable |
| Magnesium | 25 - 50 mg/kg (max 2 g) | Given in hypomagnesaemia or polymorphic VT |
Airway management
Protocol:
- Assess airway:
- If evidence of obstruction or altered consciousness:
- Perform airway-opening manoeuvres, consider suction or foreign body removal
- If obstruction persists: consider oro- or nasopharyngeal airway or LMA/i-gel
- If obstruction still persists: consider intubation (if performed, immediately check position of tracheal tube using auscultation and capnometry)
- If intubation is difficult or impossible: see failed intubation algorithm and consider surgical airway
- If stridor but relatively alert:
- Allow self-ventilation where possible
- Encourage oxygen but do not force to wear mask
- Do not force to lie down
- Do not inspect airway (except as a definitive procedure under controlled conditions)
- Assemble expert team and equipment
- If evidence of obstruction or altered consciousness:
- Assess breathing:
- If respiratory arrest or depression:
- Administer oxygen by bag-valve-mask
- SpO2 monitoring
- Consider supraglottic airway
- Consider intubation
- If respiratory arrest or depression:
Tracheal tubes:
- Cuffed vs uncuffed:
- Traditionally it has been taught that uncuffed tubes should be used in paediatrics but improvements in materials and design, and modern studies of paediatric airway anatomy have led to a gradual change in this view and the choice between them now is largely a matter of availability, preference and local protocol
- The benefits of a cuffed tube are thought to be: accurate ETCO2 monitoring, protection from aspiration, fewer tube changes due to air leaks, and continuous lung recruitment.
- The concerns about cuffed tubes are that they cause increased trauma and that this trauma can lead to erosion, infection, cricoid perichondritis, and ultimately subglottic stenosis.
- Tube size diameter:
- To estimate ETT size of emergency intubation use the following formula (if >1 year):
- Internal diameter (mm) = (Age/4) + 4
- If a cuffed tube is chosen, it may be appropriate to calculate the size using: (Age/4) + 3.5 instead
- Infants aged 6 month = size 4
- Infants aged 1 year = size 4.5
- Neonates under 3 kg usually require an uncuffed tube of size 3.0 0r 3.5 mm.
- Preterm neonates may require a smaller tube.
- To estimate ETT size of emergency intubation use the following formula (if >1 year):
- Tube size length:
- To estimate ETT length, use:
- Length (cm) = (Age/2) + 12 for an oral tube
- Length (cm) = (Age/2) + 15 for a nasal tube
- To estimate ETT length, use:
Report A Problem
Is there something wrong with this question? Let us know and we’ll fix it as soon as possible.
Loading Form...
- Biochemistry
- Blood Gases
- Haematology
| Biochemistry | Normal Value |
|---|---|
| Sodium | 135 – 145 mmol/l |
| Potassium | 3.0 – 4.5 mmol/l |
| Urea | 2.5 – 7.5 mmol/l |
| Glucose | 3.5 – 5.0 mmol/l |
| Creatinine | 35 – 135 μmol/l |
| Alanine Aminotransferase (ALT) | 5 – 35 U/l |
| Gamma-glutamyl Transferase (GGT) | < 65 U/l |
| Alkaline Phosphatase (ALP) | 30 – 135 U/l |
| Aspartate Aminotransferase (AST) | < 40 U/l |
| Total Protein | 60 – 80 g/l |
| Albumin | 35 – 50 g/l |
| Globulin | 2.4 – 3.5 g/dl |
| Amylase | < 70 U/l |
| Total Bilirubin | 3 – 17 μmol/l |
| Calcium | 2.1 – 2.5 mmol/l |
| Chloride | 95 – 105 mmol/l |
| Phosphate | 0.8 – 1.4 mmol/l |
| Haematology | Normal Value |
|---|---|
| Haemoglobin | 11.5 – 16.6 g/dl |
| White Blood Cells | 4.0 – 11.0 x 109/l |
| Platelets | 150 – 450 x 109/l |
| MCV | 80 – 96 fl |
| MCHC | 32 – 36 g/dl |
| Neutrophils | 2.0 – 7.5 x 109/l |
| Lymphocytes | 1.5 – 4.0 x 109/l |
| Monocytes | 0.3 – 1.0 x 109/l |
| Eosinophils | 0.1 – 0.5 x 109/l |
| Basophils | < 0.2 x 109/l |
| Reticulocytes | < 2% |
| Haematocrit | 0.35 – 0.49 |
| Red Cell Distribution Width | 11 – 15% |
| Blood Gases | Normal Value |
|---|---|
| pH | 7.35 – 7.45 |
| pO2 | 11 – 14 kPa |
| pCO2 | 4.5 – 6.0 kPa |
| Base Excess | -2 – +2 mmol/l |
| Bicarbonate | 24 – 30 mmol/l |
| Lactate | < 2 mmol/l |
